H&N—-DANIEL TODD, MD
H&N CA IMPLIES EPITHELIAL MALIGNANCY OF THE UPPER AERODIGESTIVE TRACT OR GLANDULAR MALIGNANCY OF THE THYROID OR SALIVARY GLANDS
STAGING
CT SCANNING PLAYS AN IMPORTANT ROLE
MELANOMA
STAGE I = LOCAL
STAGE II = REGIONAL
STAGE III = DISTANT
Tx, T0 = CIS = LENTIGO MALIGNA, MELANOMA IN SITU, HUTCHINSON’S FRECKEL, CLARK LEVEL I—->99% SURVIVAL
T1 = CLARK LEVEL II = BASAL CELL LAYER OF EPIDERMIS/PAPILLARY DERMIS, < 0.75 MM BRESLOWS LEVEL—-80% SURVIVIAL
T2 = CLARK LEVEL III = SUPERFICIAL RETICULAR DERMIS, O.76 – 1.5 MM BRESLOWS LEVEL—-50% SURVIVAL(15-20% INCIDENCE OF REGIONAL METS)
T3 = CLARK LEVEL IV = DEEP RETICULAR DERMIS = 1.51 – 4.0 MM BRESLOWS LEVEL—-30% SURVIVAL
T4 = CLARK LEVEL V = S.Q. TISSUE, OR SATALLITOSIS WITHIN 2 CM, > 4.0 MM IN DEPTH
NO
N1 = < 5 CM, SATALLITOSIS > 2 CM AWAY
CUTANEOUS BCCA AND SCCA STAGING:
T1 < 2 CM
T2 = 2-5 CM
T3 > 5 CM
T4 INVADING DEEP EXTRADERMAL STRUCTURES (CARTILAGE, MUSCLE, BONE)
N0 NO REGIONAL METS
N1 REGIONAL LYMPH NODE METS
HNSCC
TX=UNKOWN PRIMARY
T0=NOT CLINICALLY EVIDENT
TIS-IN SITU
T4 USUALLY IMPLIES INVASION OF ADJACENT STRUCTURES
OC/OP:
T1 < 2CM—–10% INCIDENCE OF MICROMETASTASIS
T2 2 – 4 CM—35% INCIDENCE OF MICROMETASTASIS
T3 > 4 CM
T4 INVADES ADJACENT STRUCTURES——BONE (MANDIBULAR) INVOLVEMENT IS DIFFICULT TO DETERMINE—-DO SOME TYPE OF IMAGING MODALITY—-OCCLUSAL SURFACE OF THE MANDIBLE IS MOST SUSCEPTIBLE TO INVASION—–FROZEN SECTION OF CANCELLOUS BONE MAY BE OF BENEFIT
THE MORE ANT THE LESION—THE LESS LIKELY REGIONAL Dz IS—THICKNESS IS ONLY A FACTOR IN TONGUE LESIONS
DORSAL TONGUE LESIONS—THINK OF SYPHILIS, GRANULAR CELL TUMORS, OR SCCA
HP/LP:
T1 LIMITED TO 1 SUBSITE (POST PHARYNGEAL WALL, POST CRICOID AREA, PIRIFORM SINUS)
T2 > 1 SUBSITE WITHOUT FIXATION
T3 HEMILARYNGEAL FIXATION
T4 INVADES ADJACENT STRUCTURES
LARYNX:
EASY WAY TO STATE IT IS ALWAYS ADDRESS THE NECKS EXCEPT IN T1 AND T2 GLOTTIC LESIONS—LESS THAN 4% INCIDENCE OF REGIONAL METS
PRE EPIGLOTTIC SPACE INVOLVEMENT IS THOUGHT BY SOME TO BE A SURGICAL Dz
SUPRAGLOTTIC:—-ALWAYS THINK ABOUT THE NECKS HERE
T1 1 SUBSITE—–THINK OF ENDOSCOPIC RESECTION
T2 > 1 SUBSITE
T3 FIXATION—-MUST DISTINGUISH MASS EFFECT FROM INVASION
T4 INVADES ADJACENT STRUCTURES
GLOTTIC:
T1A ONLY 1 TVC
T1B B TVC
T2 SUPRA OR INFRA GLOTTIC EXTENSION
T3 FIXATION—THINK ABOUT THE NECKS FOR ALL GLOTTIC T3 AND T4′S
T4 INVADES ADJACENT STRUCTURES
SUB/INFRA-GLOTTIC (10 MM BELOW TVC TO INF BORDER OF CRICOID)—ADDRESS THE NECK ALWAYS
T1 ISOLATED TO REGION
T2 EXTENDS TO TVC
T3 FIXATION
T4 INVADES ADJACENT STRUCTURES
TRANSGLOTTIC = EXTENDS FORM INFRA (10 MM BELOW GLOTTIS) TO SUPRAGLOTTIC (TO FVC’S) REGIONS—-
PAROTID
T1= <2CM
T2= 2-4CM
T3= 4-6CM
T4= >6CM
MAXILLARY SINUS
T1= TUMOR LIMITED TO ANTRAL MUCOSA
T2= INVADES INFRA STRUCTURE BONE
OHNGREN’S LINE—–PUNCTUM TO MANDIBULAR ANGLE
T3= INVADES SUPRA STRUCTURE BONE
T4= INVADES SKULL BASE OR ORBIT
NODAL STAGING
N1 = SINGLE, IPSI, < 3 CM
N2A= SINGLE, IPSI, 3-6CM
N2B = IPSI, MULT OR > 6 CM
N2C = CONTRA OR B, < 6 CM
N3 = CONTRA OR B, > 6 CM
DELPHIAN LN (PROPHETIC ORACLE OF DELPHI) INDICATIVE OF EITHER METASTATIC LARYNX OR THYROID CA
NP:
T1 CONFINED TO NP
T2A NP OR OP EXTENSION
T2B PARAPHARYNGEAL EXTENSION
T3 BONE INVASION
T4 INTRACRANIAL, CN NEUROPATHY, INFRATEMPORAL FOSSA, HP, ORBITAL EXTENSION
USE EBV IGA FOR SURVEILLENCE AND DETECTION OF UNKOWN PRIMARY
N1 = UNILAT, < 6, HIGH
N2 = B, > 6, HIGH
N3A = >6CM, HIGH
N3B = LOW (SUPRACLAVICULAR FOSSA LAD)
THYROID
T1= <1CM
T2= 1-4CM
T3= >4CM BUT CONFINED TO CAPSULE
T4= ANY SIZE WITH EXTRACAPSULAR EXTENSION
N1= REGIONAL LAD
N1A= IPSI LAD
N1B= CONTRA, B, MIDLINE, OR MEDIASTINAL LAD
SURVIVAL FOR H & N SCCA
TI,N0=70%,N1(IPSI<3CM)=50%,N2A OR WORSE (IPSI 3-6CM), ECS/FIXATION OR N3 NECK=10% 5 YEAR SURVIVAL (70% ECS IF LN > 3 CM)—-ECS ACTUALLY 23% IN LN METS LESS THAN 1 CM—ECS IS AN INDEPENDENT PREDICTOR OF BOTH REGIONAL RECURRENCE AND SURVIVAL
UP TO A 5% INCIDENCE OF 2ND PRIMARY PER YEAR IN THIS SUBSET OF PTS
PNI (PERINEURAL INVASION) IS A POOR Px INDICATOR—TUMOR CAN EXTEND UP TO 12 CM ALONG THE EPINEURIUM
CAROTID ARTERY RESECTION—20% SURVIVAL—20% INCIDENCE OF NEUROLOGIC SEQUELAE (DO AN OCCLUSION TEST AND CONSULT VASCULAR SURGERY)
YOUNG PTS (<40)—MORE FEMALES, LESS SMOKERS, LESS SECOND PRIMARIES, MORE OC, OP SITES——NO DIFFERENCE IN SURVIVAL
USUALLY DO AN ELECTIVE NECK DISSECTION IF > 20-25% CHANCE OF METS IN N0 NECK—DO NECK PLUS RT IF—STAGE I Dz WITH LEVEL III LAD OR STAGE II Dz WITH LEVEL II LAD
RECURRENCE—85% IN 1ST YEAR, 96% WITHIN 2 YEARS—THUS F/U CONCENTRATED IN 1ST 2 YEARS
NEW DATA IS SUPPORTING A MINIMALIST F/U BASED ON PTS SYMPTOMS—PT EDUCATION IS IMPERATIVE!
PET SCANNING MAY BE APPROPRIATE TO MONITOR RECURRENCE IN IRRADIATED PTS (A MINIMUM OF 4 MONTHS POST RT)
CAVEATES
P53 IS A LOCUS ON THE SHORT ARM(P) OF THE 17TH CHROMOSOME WHICH IS PROBABLY A TUMOR SUPPRESSOR GENE—ENCODES A PROTEIN WHICH KEEPS THE CELL FROM ENTERING THE CELL CYCLE—LOCKS IT IN G1
FIELD CANCERIZATION “CONDEMNED MUCOSA”—CONSIDER TOLUIDINE BLUE/SUPRAVITAL STAINING TO BETTER DEFINE SUSPICIOUS MUCOSA IN LEUKOPLAKIA, ERYTHROPLAKIA,SUBMUCOUS FIBROSIS AND CIS ARE ALL PREMALIGNANT——- PLACE ON BETA CIS-RETINOIC ACID (RETINAE)—–PRIMARY SIDE AFFECT IS ANGULAR CHELITIS—-CONSIDER LASER, WLE, AND RT
SPECKLED LEUKOPLAKIA HAS EVEN MORE MALIGNANT POTENTIAL
A 3-7% PER YEAR INCIDENCE OF A 2ND PRIMARY
FOR CHEMO RT PROTOCOL TO WORK THEY NEED A RESPONSE TO THE CHEMO!—-CHEMOS ROLE AS A NEOADJUVANT AGENT ISFIRST AND FORMOST TO PREDICT WHICH PATIENTS MAY BE CANDIDATES FOR ORGAN PRESERVATION AND SECONDLY TO DECREASE THE INCIDENCE OF DISTANT METASTASIS
NEO-ADJUVANT=GIVEN BEFORE, CONCURRENT=GIVEN WITH, ADJUVANT=GIVEN AFTER
FOR CHEMO RT “LARYNGEAL PRESERVATION PROTOCOL”—IDEAL TIME FOR ELECTIVE NECK IS 4-6 WEEKS AFTER—POINT AT WHICH INFLAMATION HAS DECREASED MOST IN RELATION TO INCREASING FIBROSIS
PERSISTENT LARYNGEAL EDEMA AFTER RT—MOST OFTEN REPRESENTS RECURRENCE—SECONDLY RADIOCHONDRONECROSIS
X-RAYS ARE PRODUCED BA A LINEAR ACCELERATOR MACHINE, GAMMA RAYS ARE PRODUCED BY RADIOACTIVE DECAY “COBOLT”
FOR RT XEROSTOMIE—FLOURIDE AND FLOSSING ARE PARAMOUNT—–PILOCARPINE(OPTHO DROPS ARE CHEAPER)—BEATING A DEAD HORSE, SUCRULFATE, AMIPHOSTINE—EXPERIMENTAL–COMBATS XEROSTOMIA AND MUCOSITIS FROM RT—-MAY ALSO HELP PROTECT THE KIDNEYS FROM CHEMO (A FREE RADICAL SCAVENGER), AND EARLY PEG
BILATERAL TONSILLECTOMY IS PROBABLY A GOOD IDEA IN PTS WITH THE UNKNOWN PRIMARY
HAVE A LOW THRESHOLD TO CT SCAN THE CHEST
STOMAL STENOSIS
DILATE TO A #8 LARYNGECTOMY TUBE, WEAR FOR 6 MONTHS. IF PROBLEM PERSISTS CONSIDER A STOMAL REVISION WITH LOCAL FLAPS